Application

Massachusetts Legal Assistance for Self-Sufficiency Program. A Project of South Coastal Counties Legal Services, Inc.

IMPORTANT: The information in this form will not be saved. If you would like to fill out the the information in a Word Document please download it here and email the completed application to KMarx@sccls.org.

NAME / ADDRESS

First Name
Last Name

CURRENT ADDRESS: All information will be sent to this address unless you notify us of a change.
Address
Number and street (When using a PO Box, please include a street address)

City State Zip Code
Home Phone
Work Phone
Cell Phone
*Email
I can be contacted at this address/ number until

PERMANENT ADDRESS: (If different than above)

Address
Number and street (When using a PO Box, please include a street address)

City State Zip Code
Home Phone
Work Phone
Email

EDUCATION

Check the highest level of education that you will have completed by the time you plan to serve in AmeriCorps (Check only one):
Associate's Degree Bachelor’s Degree
Law Degree (check year completed) L1 L2 L3
Other Graduate Degree Please specify

Bar Admission in Massachusetts In other state?
(Please specify)

Do you plan to attend law school at night while participating in the program?
Yes No

COMMUNITY SERVICE

In the space below, describe your involvement in service. How have you reached out to help others, your community, or another community? In the reflection section, elaborate on why you decided to get involved, what you learned, and how it affected you.

Organization 1

Dates of involvement:
From To
Organization Name
Location
Contact Person
Telephone
Email

Description of involvement:

Reflection on service experience:

Organization 2

Dates of involvement:
From To
Organization Name
Location
Contact Person
Telephone
Email

Description of involvement:

Reflection on service experience:

AmeriCorps Experience
Have you previously served in AmeriCorps? Yes No

Dates of involvement:
From To
Did you complete your term of service? Yes No
Program Name
Location
Contact Person
Telephone
Email

Description of involvement:

Reflection on service experience:

SHORT ANSWERS

Please answer the following questions as concisely as possible.

1. Please describe why you want to serve in this Legal Assistance for Self-Sufficiency AmeriCorps program. Current members reapplying are asked to explain why they would like to do a second year in this program.

2. Please describe any specific relevant education, experience, or skills you have that you think would be an asset to the Legal Assistance for Self-Sufficiency AmeriCorps program and the clients served by this project.

3. What are your career goals?

4. What interests you about public service law?

5. Do you have plans to attend college, to dedicate a significant amount of time to an academic project (such as a thesis), or to engage in employment during the next year?

6. Do you have any personal issues, concerns or priorities which could adversely affect your commitment or ability to complete the program?

GEOGRAPHIC PREFERENCES

Listed below are the regions of Massachusetts where our community based partner law firms are located. Please select one option:
I can work in any region
I can work only in region (enter region)

SURVEY

Please answer the following questions:

1. Are you a U.S. Citizen, U.S. National, or lawful permanent resident alien of the U.S.? Yes No
2. Are you 17 years or older? Yes No
3. Are you available from early September 2009 to late July 2010? Yes No

4. Do you have reliable transportation for the duration of the program?
Yes No
5. Do you object to a criminal records check (CORI)? Yes No
6. How did you hear about the program?

7. List non-English language/s in which you are fluent.
Language Speaking Writing
Language Speaking Writing
Language Speaking Writing

8. AmeriCorps asks for collection of demographic information
as follows. (Optional)

Describe your ethnic background. Check all that apply.
African American
Non- Hispanic/Latino/Spanish
American Indian or Alaskan Native
White
Asian
Hispanic/Latino/Spanish
Native Hawaiian or Other Pacific Islander

Gender: Male Female

The Legal Assistance for Self-Sufficiency program is an equal opportunity project, available to all, without regard to race, color, national origin, disability, age, sex, sexual orientation, political affiliation, or religion; it is committed to the inclusion of people with disabilities as members and will provide reasonable accommodations upon request to SCCLS.

REFERENCES

Please list three references from a variety of job, academic or community service sources:
First Name Last Name
Address
City State
Telephone
Email
Relationship
How long has this person known you?

First Name Last Name
Address
City State
Telephone
Email
Relationship
How long has this person known you?

First Name Last Name
Address
City State
Telephone
Email
Relationship
How long has this person known you?

I attest that the information provided in this six-page application is true and correct to the best of my knowledge. I give the program permission to contact my three listed references.

Please type the letters you see to help us minimize SPAM.

P.O. Box 2507 Fall River, MA 02722-2507
Phone: 508-676-5022 Ext. 20 - Fax: 508-676-8657 - KMarx@sccls.org
Copyright © 2009 Massachusetts Legal Assistance for Self-Sufficiency Program
South Coastal Counties Legal Services Inc.
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